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AAPC Chapter 4

ICD-10-CM coding

QuestionAnswer
For HIV code only _____ cases. confirmed
Code ____ if pt is admitted for HIV related condition. And this is always first unless the ______ B20, exception
Infectious and Parasitic Diseases: 2 codes- one for organism and one for _____, or combination code or _____ code. condition, single
Infectious Diseases: B20 should be _____ code and use additional code to identify any associated _____ listed. principal, manifestations
Coding for HIV: is it _____ or known to have had HIV or related condition in the past? What is the purpose of the _____ or encounter? asymptomatic, admission
HIV sequencing rules : follow when pt being treated for HIV related or non- _____ related condition. HIV
Inpatient. HIV is only condition that MUST be confirmed as: stating ____, or pt is being ____ for any documented HIV related illness or has condition _____ from HIV status AIDS, treated, resulting
HIV sequencing depends on the _____ for admission or encounter. Exception to this: reason for admission is hemolytic- uremic syndrome associated with the HIV and then this is reported _____, B20 is 2nd. reason, first
Pt with HIV admitted for _____ condition, the code for this is coded first. unrelated
Z21- Asymptomatic HIV: pt HIV ____ but no documented symptoms. Do not use if ____ term is used. If pt being treated for any HIV illness or described as having any condition resulting from HIV + status use code _____ positive, AIDS, B20
Pts with inconclusive HIV serology and definite diagnosis or manifestations of it use code _____ for inconclusive laboratory evidence of HIV R75
HIV: never assign R75 or Z21 to a pt with an _______ diagnosis of AIDS or symptomatic HIV earlier
HIV during pregnancy: code from Z3A for the _____ of gestation. weeks
Pt believes has been exposed to HIV code ______ Z20.6
Code Z79.899 for long term use of _____ meds antiviral
Code Z16 category code for resistance to _____ drugs antimicrobial
Sepsis diagnosis: code the ______ systemic infection underlying
R65.2: _____ sepsis severe
Sepsis with acute organ dysfunction is considered _____ sepsis severe
If sepsis and acute organ dysfunction but med record says acute organ dysfunction is related to medical condition other than sepsis, don't code ______ R65.2
Severe sepsis: 2 codes- code for underlying _____ then code from category R65.2 infection
A41.9: sepsis, ______ organism unspecified
Pt has sepsis with MOD: list a code to identify ____ organ dysfunction each
Septic shock: code _____ the underlying systemic infection followed by R65.21- severe sepsis with septic shock first
Pt may develop sepsis following a procedure. If provider notes causual _____ between the sepsis and procedure is it considered Post-procedural complication. relationship
T81.44 is code for _____ following a procedure sepsis
If the infection meets the definition of principal diagnosis it should be sequenced before non-_____ condition infectious
If the reason for infection is hemolytic-uremic syndrome associated with sepsis code hemolytic-uremic syndrome _____ first
MRSA: there are ______ codes to report the infection and causual agent combination
If pt is a carrier to MRSA and doesn't have an ____ infection code Z22.322-carrier or suspected carrier of MRSA active
Z86.14 code for personal ____ of MRSA history
Zika Virus: only ______ diagnosis reported. confirmed
Zika virus: code A92.5 unless it says probable, possible or suspected then _____ or exposure codes reported. symptoms
Coronavirus: only code _____ diagnosis. U07.1- Covid 19 confirmed
Pt admitted for manifestations of Covid -19, ______ is reported, followed by manifestations code. U07.1
Even if + covid test but ______ use code U07.1 since they're + asymptomatic
Pt had exposure or _____ exposure of covid and is asymptomatic report code Z20.822 suspected
If pt has Covid symptoms and has had or suspected of having _____, code Z20.822 in addition to _____ codes exposure, symptoms
Z86.16: history of _____ Covid-19
Pt seen for f/u with history of Covid with residual symptoms and negative test, report Z09- encounter for f/u after completed treatment for conditions and the personal ____ code reported history
Covid antibody testing Z01.84 unless the visit is to confirm _____ infection or is f/u test after resolution current
When pt has pos covid-19 condition or sequelae, report the specific ______ and code U09.9 condition
Both U09.9 and U07.1 can be reported when manifestation and sequalae of prior conditions exists at the _____ time of a new active covid 19 infection same
Pt with HIV admitted for unrelated condition, code the ______ condition first unrelated
Severe sepsis: _____ code for underlying condition then from R65.2 category first
J15.212- pneumonia due to ______ MRSA
Neoplasms: if histology is known look for the term in _____ or in table of neoplasms Index
Primary malignancy: where the cancer ______ originates
Secondary Malignancy: results from ______ and forms a new focus of malignancy elsewhere metastasis
In situ: confined to the ____ site origin
In Situ: encapsulated and doesn't ______ neighboring tissue invade
In situ also called non-______, non-invasive and pre-invasive filtrating
Atypia or dysplasia: neoplasm is in transition from _____ to malignant. Also has _____ behavior. benign, uncertain
Neoplasms: Pathology report is best for most _____ code specific
Neoplasms: Reccomended to hold claims until _____ report is returned pathology
Neoplasms: until pathology is recieved use code ____ from table of neoplasms unspecified
For malignant: determine primary and secondary site and code 1st the site _____ care. requiring
If Primary cancer is still ____ and represents the reason for the service list the code for the primary site 1st active
Neoplasms: if secondary growth is the reason (primary) for care, choose from secondary column in neoplasms and list _____ first
Multiple malignant neoplasms of same site: when sites are next to each other- category for ____ lesion should be used overlaping
Contiguous: when sites are ____ to each other next
When malignancies are the same site but not next to each other code for ____ site. each
Malignant neoplasms of ectopic tissue: coded to the site of ____ mentioned. origin
Malignant neoplasms of ectopic tissue: if primary site not available when encounter is directed at secondary (metastic) site select code for _____ site first then code C80.1 for unspecified. primary
Anemia because of the neoplasm and getting treatment for anemia: the code for the ______ is listed first followed by code for Anemia malignancy
If anemia is caused by chemo or radiation: anemia code reported ____ then code for neoplasm and adverse effect first
Dehydration because of malignancy and only dehydration is being treated: first code for ______ then code for malignancy dehydration
Neoplams: when encounter directed at a surgery complication: the surgery complication is _____ diagnosis primary
After neoplasm treated successfully: inapropriate to use _____ codes for f/u care neoplasm
Z85: personal history of ______ neoplasm. The primary malignancy has been removed and no longer being treated. Also, pt not receiving chemo or radiation for an _____ neoplasm. No evidence of any _____ malignancy malignant, active, remaining
Surgical removal of neoplasm: code as if it ____ exists, don't use history of code still
When treatment for eradicated cancer is complete: ____ code can be assigned history
If complications develop during chemo, radiation or immunotherapy: code for those first followed by code for _____ complications
Determining the extent of malignancy visit or procedure: the primary malignancy or metastatic site is designated as the ____ listed diagnosis despite the administration of chemo etc. first
Sequencing neoplasms: primary malignancy, secondary malignancy, _____ pt with malignant neoplasm, complication associated with neoplasm, complication from ______ for treatment of neoplasm, pathalogic fracture due to neoplasm. pregnant, surgery
Leukemia and multiple myeloma and malignant plasma cells: have codes for when in ______ remission
Malignant neoplasm of transplanted organ requires 3 codes: first report the transplant ______, next code C80.2, then code to _____ malignancy. complication, specify
Follicular lymphoma: coded by _____, often a scale of 1-3 which designates how many large cells are found in a high power field (centroblasts. grade
Follicular Lymphoma: to code understand not only the grades but also _____ affected nodes
When pt has primary cancer that metastasized to to lymph nodes the ____ is not reported with C81-C96, tabular list refers you to C77 node
Lymphoma that metastasizes beyond the lymph node assign code C81-C85 with final character of ____ rather than code for secondary malignancy of the solid organ. 9
Neoplasm with pain: code G89.3. Doesn't have to state whether ____ or chronic. Pain coded first the _____ code as additional acute, neoplasm
When reason for visit is management of neoplasms and pain associated with neoplasm: code ____ is additional code G89.3
Functional activity: functional neoplasms make and release hormones and other substances that cause _____ symptoms
Functional activity codes: endocrine, nutritional and _____ diseases. metabolic
Anemia: see if provider documented the cause. When cause isn't documented the code for _____ anemia (D64.9) is only option. unspecified
If anemia is caused by ____ and the treatment is focused on the anemia the ____ code is 1st followed by code for the neoplasm then adverse effect of antineoplastic chemo chemo, anemia
Anemia caused by CKD: code for _____ reported 1st then code for anemia CKD
When coding from (D63), diseased classified elsewhere, code the _____ condition causing the anemia first chronic
When pt admitted for management of anemia d/t malignancy and treatment is _____ for anemia code for malignancy first, followed by anemia code. only
Thyroidoxicosis: code for with and without thyroid _____ storm
DM: combination codes that include: type of DM, body system affected and _____ affecting that body system complications
____ diabetes melitus categories 5
All diabetes categories have notes directing to use additional code for use of _____, oral antidiabetic drugs and oral hypoglycemic meds. Ecept E10- type ___ DM insulin , 1
E10.52: Type 1 DM with diabetic peripheral angiopathy with _____ gangrene
DM E10-E13 sequenced first followed by codes for _____ complications additional
DM E08-E09: code first note indicating that diabetes is sequenced _____ the underlying condition, drug or chemical responsible for the diabetes. after
Assign codes E08-E13 as many times needed to identify all associated _____ the pt has conditions
Long term use of insulin (Z79.4) should _____ be used if insulin given temporarily to bring type 2 pt blood sugar under control not
If pt takes insulin long-term and injectable non-insulin diabetic drug code for ____ both
DM _____ pt, always sequenced first pregnant
Pre-existing DM and becomes pregnant: code 024 (DM in pregnancy) followed by the ____ code diabetes
DM: 4th character identifies ____ of diabetes as pre existing, type 1, Type 2, unspecified or _____ type, gestational
DM: pregnant : 5th character indicates whether the diabetes is treated during ____, childbirth or puerperium. pregnancy
DM: pregnant: 6th character indicates whether the gestational diabetes is diet controlled, _____ controlled or controlled by hypoglycemic drugs or unspecified control insulin
Insulin pump failure: under ____ of insulin due to pump failure code T85.6. dose
Mechanical complications of internal/external implants as first code followed by code T38.3X6 (underdosing of insulin and or hypoglycemic drugs) Then add codes for ____ of DM and associated symptoms. type
Secondary diabetes: E08 &E09- identify _____/manifestations associated with secondary DM complications
Secondary diabetes: caused by something other than ____ or environmental factors genetics
High blood sugar levels that develop as the result of another medical condition: _____ diabetes. secondary
Secondary diabetes: may also develop when _____tissue responsible for the production of insulin is absent because it is destroyed by a disease. pancreatic
Secondary diabetes is ____caused by another condition or event always
Post pancreatectomy DM code E89.1- postprocedural hypoinulinemia. Code from category E13 and code from Z90.41-aquired absence of pancreas as ____ additional
Code Z90.41 has "use additional" to code insulin use ______ pancreatectomy. post
Coding for obesity includes ____ of obesity cause
Obesity: also code for if it's considered ____ morbid
Obesity: secondary code from Z68 also used when the codes for underweight, _____and obesity are used. Z68.37- BMI 37.0-37.9, adult. overweight
If code for psychiatric services the ____ should be used as a reference DSM-5
Code F45.42 when pain with psychiatric factors with an additional code for acute or chronic _____ pain
Mental and behavioral disorders due to psychoactive substance use: When documentation says: use, abuse and dependence of the same_____, only 1 code is assigned to identify the pattern. substance
Mental and behavioral disorders due to psychoactive substance use: In remission- assigned _____ on the basis of provider documentation only
Psychoactive substance use: Remember excludes 1 notes to identity the correct way to code for "use," "______," and "dependence" abuse
Mental and behavioral disorders due to psychoactive substance use: the type of _____ use is identified with the 3rd character. The 4th character indicates abuse, _____ or use substance, dependence
Mental and behavioral disorders due to Psychoactive substance use: 5th character indicates the ____ of condition (such as intoxication, etc). The 6th character indicates further specific _____ (such as delusions) state, complications
The blood alcohol level _____ need to be documented by provider doesn't
Depression classified by episodes in addition to types: mild, _____, severe and without psychotic features. moderate
Factitious disorders: imposed on self code F68.1, Imposed on another code F68.A and adult and child ____ confirmed or adult and child abuse, suspected abuse
Intellectual disabilites: first code any associated ____ or developmental disorder and then code for intellectual disorder. physical
Intellectual disabilities: coded by stage such as mild, moderate, severe and _____. Stage determined by _____ level. profound, IQ
ADHD: coding is either predominately, hyperactive, _____, or combined type. inattentive
Dementia: there is a note to code 1st the underlying physiological condition- this says ____ codes required and the code for dementia sequenced 2nd. 2
Dementia: if severity progresses during hospital stay (inpatient) the _____ level of severity during stay is reported. highest
Parkinson's disease: codes have additional notes for reporting if dyskinesis or _______ present. fluctuations
Alzheimer's disease: code based on _____ or late onset early
If dementia with Alzheirmer's is documented ____ codes required 2
Focal (partial) seizure: only occur in ____ part of the brain one
Generalized seizures: both ____ of brain and include absence, tonic, ____, tonic-clonic, myotonic and atonic sides, clonic
Focal Seizures include: simple and ______ complex
Simple focal seizures: pt remains conscious but has _____ and feelings that's abnormal sensations
Type of focal seizure where pt has change in loss of consciousness: Complex
Absence seizures: (petit mal) _____ into space or have twitching muscles. stare
Tonic seizures: stiffening of _____. Clonic: repeated jerking of muscles on ___ sides of body. Tonic-clonic (grand mal): _____ muscles, both, mixture
Atonic: loss of normal muscle _____. Myoclonic seizure: jerks and twitches of the upper body, arms and _____ tone, legs
Status Epilepticus: when seizure lasts an _____ long time. Usually longer than 5 mins. abnormally
"poorly controlled": _____ intractable
Intractable migrain: cannot be controlled with _____ medication
Migrains: 5th character identifies if ______, 6th character identifies with or without _____ migrainosus (ongoing for longer than 72 hours) status
Migrain with aura: classic, without aura: ______ migrain common
If affected side is not specified as dominant or non dominant and there's no default use the ____ for coding rules
Ambidextrous: default is _____ dominant side
If left side is affected: default is _____ non- dominant side
If right side is affected: default is ____ side. dominant
Need to know if it's acute or chronic to code correctly: pain
Pain management: code from G89 then code for _____ condition underlying
Pain: When encounter is to treat the underlying disease, 2 codes required. First code for underlying condition followed by ____ code pain
Routine or expected post-op ____ is not reported. (immediately following surgery) pain
Post-op pain not recorded as acute or chronic is coded as _____ acute
Post-op pain associated with specific complication the code for complication is ____ code, with code from G89 as second primary
Pt admitted for insertion of neurotransmitter for pain control assign appropriate ____ code as 1st listed pain
Glaucoma H40: 4th character indicates _____, 7th character needed for many to indicate ____ site, stage
Glaucoma: when both eyes affected by same _____ of glaucoma and same stage and there is a bilateral code, only 1 code reported. type
Glaucoma: "4" for 7th character used as inderminate stage for when documented stage ____ be determined cannot
Glaucoma: 7th character "0" when stage _____ unspecified
Blindness: category based on visual acuity with the ____ possible correction best
Blindess: when category not documented the code is based on ____ eye affected
Use code H54.7 for ___ visual loss when neither visual impairment category or affect are aren't documented unspecified
Blepharitis and conjunctivitis based on ____ and eye/eyelid affected type
Acute otitis media: one or more of these symptoms: otalgia, _____, otorrhea, recent onset anorexia, irritability, vomiting, and ____ fever, diarrhea
MEE: middle ear _____ effusion
OM (otitis media) with effusion is is MEE of any duration _____ s/s of infection and usually follows AOM (acute otitis media) lacking
Chronic suppurative OM: at least 6 weeks, ottorhea through _____ TM , an indwelling tympanostomy tube or sugical myrinotomy perforated
Providers must document the ____ and effect relationship between care provided and the condition and the indication that it is a ______ cause, complication
Hypertension: pay attention to Exludes and Includes notes, also use _____ for exposure to tobacco smoke, history of use and current use of tobacco additional
Hypertension and CKD code _____. Only code separate when clearly states they're not _____ together, related
HTN transient: increased BP _____ hypertension. (ex: white coat syndrome). without
Pulmonary HTN: reason for encounter determins sequencing _____ for adverse effects- follow guidelines for adverse effects except
Secondary pulmonary HTN: pulmonary HTN as result of another _____ or medication condition
CAD: code to report the areas of _____ atherosclerosis
CABG in the past: code is selected based on type of _____ graft
Combination code for angina, heart disease and _____ atherosclerosis
CVA sequelae codes specify hemiplagia, hemiparesis, and monoplegia, specify whether ____ or non dominant side affected. dominant
CVA: use additional notes to report condition, syndrome or ____ as secondary code sequelae
MI: 5 types: Type 1, Type 2 , with code for underlying _____ cause
MI: type 3-5: _____ MI's acute
Acute MI is if duration is ____ weeks or less 4
This type of MI can also be classified whether there's ST segmnet elevation: Type 1
STEMI: if location isn't specified use code I21.3
MI: code selection identifies the episode of care. Episode options include: episode of care _____, intitial episode of care, _____ episode of care unspecified, subsequent
Intraoperative and postprocedural complications: 4th and 5th characters indicate type of _____ except codes ending in .8, .88 or .89 complication
Intraoperative and postprocedural complications: 6th character indicates complication followed by a ____ or procedure surgery
If STEMI converts to NSTEMI from thrombolytic treatment it is still coded as _____ STEMI
HTN and CKD doesn't require cause and effect relationship to be documented it has "______ effect" presumed
COPD: look for ____/pulmonary/chronic/ obstructive. J44.0 disease
Asthma: severity should be documented as severe persistant, ____ persistant or moderate persistant, and intermittent mild
_____: determin if it's exacerbated Asthma
Respiratory failure: codes selected by acute, chronic, unspecified and if presence of _____ or hypercapnia. hypoxia
ARF: sequencing determined by the ____ for encounter. If pt is admitted for ARF code for ARF _____ reason, first
ARF: if pt admitted for multiple reasons select the condition that required the ___ care most
Pneumonia: code selected based on _____ that caused it infection
VAP: ventilator associated pneumonia- provider must ____ it is associated document
Plueral effusion: if it's a symptom of an underlying disease only ___ code for underlying disease one
Reflux esophagitis: code based on whether it's with or without _____ bleeding
Cholelithiasis: acute, chronic, or _____ or without cholecystitis or without obstruction both
Hernias: diagnosis selected based on anatomic site and whether an ____ or gangrene is present obstruction
_____ hernias: make sure to indicate unilateral or bilateral Inguinal
Recurrent means they had hernia in the ____ past
Diagnosis code sequincing first listed diagnosis is: Eval and Management documentation- the primary ____ for the visit. Progress notes or ____ notes- the primary reason for the visit. Operative reports- the reason the ____ was performed reason, procedure, procedure
Created by: mlovest
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